Application for Variable Universal Life (VUL) Insurance
___New Application
Allianz Life Insurance Company of North America- ___Existing Policy Change
5701 Golden Hills Drive, Minneapolis, MN 55416
A. Proposed Insured
Sex __ Female
____________________ ___________________ ______________ __ Male
Name(Last, First, MI) Birth Date (MM/DD/YY) Place of Birth
______________________________________ ______________________ _______________
Street Address Apartment/Suite Number Drivers License Number E-mail Address
_______________________________________________________________________________
City State Zip Code Social Security Number Best Time to Call
_____________ __________ ___________________________ _____________________
Employer Name Occupation Hourly/Monthly/Annual Income Business Phone Number
_________________
Home Phone Number
B. Proposed Owner (if different from Insured)
Sex __ Female
____________________ ___________________ ______________ __ Male
Name(Last, First, MI) Birth Date (MM/DD/YY) Place of Birth
(If trust, include trust name, date and trustee(s))
______________________________________ ______________________ _______________
Street Address Apartment/Suite Number Drivers License Number E-mail Address
__________________________ _____________________________ _____________________
City State Zip Code Social Security/Tax ID Number Relationship to Insured
_____________ __________ ___________________________ _____________________
Employer Name Occupation Hourly/Monthly/Annual Income Daytime Phone Number
_________________
Best Time to Call
C. Product Information
Plan of Insurance (choose only one):
Allianz Variable LifeFund __ Allianz VUL- Guideline Premium Test __
Allianz VUL-Cash Value Accumulation Test __
D. Coverage Information
Amount of Insurance (Face Amount)$_______
Total Amount of Life Insurance currently in force $____________
Death Benefit Option......__ A (Level)
.....__ B (Face amount plus Accumulation Value)
Stipulated Annual Premium $_____Monthly EFT__ Quarterly__ Semi-Annual)__Annual__
E. Beneficiary(ies) Designation
Primary Beneficiary(ies)
__________________________________________________________________________
Name Social Security Number
___________________________________________________________________________
Relationship to Insured / Date of Birth / Percentage
_________________________________________________________________________
Name Social Security Number
___________________________________________________________________________
Relationship to Insured / Date of Birth / Percentage
Contingent Beneficiary(ies)
__________________________________________________________________________
Name Social Security Number
___________________________________________________________________________
Relationship to Insured / Date of Birth / Percentage
_________________________________________________________________________
Name Social Security Number
___________________________________________________________________________
Relationship to Insured / Date of Birth / Percentage
F. Replacement
1.Is this application for insurance to replace or change any life insurance or
annuities in force with this or any other company? __ Yes __ No.
If yes, list each policy to be replaced, give the name and address of
company(ies) and complete the appropriate state required replacement forms.
(If additional space is needed attach a blank sheet.)
Company:______________________________________________________________________
Address:______________________________________________________________________
Amount of Insurance currently in force $______________________________________
2. Is this a 1035 Exchange? __Yes (If yes, complete appropriate forms) __ No
G. Short-form Questions
The following three questions are required to be answered for the proposed
insured at the time of application.
YES NO
1. Have you been diagnosed by a member of the medical profession as
having HIV infection, Acquired Immune Deficiency Syndrome (AIDS) or
AIDS Related Complex (ARC), or received treatment from a member of
the medical profession for HIV, AIDS or ARC?........................ ___ ___
2. Have you ever been medically diagnosed or been treated for: ALS,
cancer, coronary artery disease, kidney failure, or stroke? ___ ___
3. If [Allianz Variable LifeFund] plan of insurance is selected,
but Insured is not eligible for such plan of insurance during the
underwriting process, should [Allianz VUL- Cash Accumulation Test]
policy be issued?.................................................. ___ ___
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H. Suitability
Yes No
A. Did you receive a copy of the applicable prospectus? ____ _____
B. Do you understand that for variable life insurance the
death benefit, cash value, and duration of coverage may
increase or decrease based on the investment experience
of the underlying Variable Options? ____ _____
C. Do you believe that the insurance selected will meet your
financial objectives? ____ _____
D. Please send transaction confirmation statements and proxies to
(check only one of the following): __ Owner __Insured ___Other
(Indicate Name and Address below):
_______________________________________________________________________________
Name Street Address City, State, Zip Code
I. Investment Options
AIM
____% AIM V.I. Capital Appreciation PIMCO
____% AIM V.I. Growth ____% PIMCO VIT High Yield Bond
____% AIM V.I. International Equity ____% PIMCO VIT StocksPLUS Growth
____% AIM V.I. Value and Income
ALGER ____% PIMCO VIT Total Return Bond
____% Alger American MidCap Growth SELIGMAN
____% Alger American Small Capitalization ____% Seligman Global Technology
____% USAllianz American Growth ____% Seligman Small-Cap Value
____% USAllianz Strategic Growth JENNISON
DAVIS ____% SP Jennison International
Growth
____% Davis VA Financial ____% SP Strategic Partners Focused
Growth
____% Davis VA Real Estate VAN KAMPEN
____% Davis VA Value ____% USAllianz Aggressive Growth
FRANKLIN TEMPLETON ____% USAllianz Capital Growth
____% Franklin Growth and Income Securities ____% USAllianz Comstock
____% Franklin Rising Dividends Securities ____% USAllianz Growth and Income
____% Franklin Small Cap ____% Van Kampen LIT Emerging Growth
____% Franklin U.S. Government AZOA (ALLIANZ OF AMERICA, INC.)
____% Mutual Discovery Securities ____% USAllianz VIP Diversified
Assets
____% Mutual Shares Securities ____% USAllianz VIP Fixed Income
____% Templeton Developing Markets ____% USAllianz VIP Global
Securities Opportunities
____% USAllianz VIP Growth
____% Templeton Growth Securities ____% USAllianz VIP Money Market
J.P. MORGAN
____% J.P. Morgan InternationalOpportunities____% Allianz Life Fixed Account
____% J.P. Morgan U.S. Disciplined Equity
OPPENHEIMER
____% Oppenheimer Global Securities/VA ____ TOTAL (Must Equal 100%)
____% Oppenheimer High Income/VA
____% Oppenheimer Main Street Growth &
Income/VA
J. Telephone Transfer Authorization
__ I/We authorize Allianz Life Insurance Company of North America (Allianz
Life) to honor telephone instructions from the Owner(s) to transfer Policy
values among the Investment Options
__ I/We authorize Allianz Life to accept telephone instructions from the
Registered Rep/Agent of Record for this Policy and/or the Representatives
Assistant(s) to transfer Policy values among the Investment Options.
If no selection is indicated, telephone access authorization will be permitted
for the Owner(s) only.
This authorization is subject to the terms and provisions in the Policy and
Prospectus. Allianz Life will employ reasonable procedures to confirm that
telephone instructions are genuine. If Allianz Life does not, it may be liable
for any losses due to unauthorized or fraudulent transfers.
We may modify, suspend, or discontinue these telephone transaction privileges
at any time without prior notice. This authorization is valid until written
cancellation is received at the Service Center.
K. Prospectus and Report Delivery
__ Please send me my annual USAllianz life insurance Prospectus, portfolio
updates and periodic reports, including the Allianz Life Privacy Notice,
electronically. (If the box is not checked, then your Prospectus will be
mailed. Please complete the appropriate form.)
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L. Temporary Insurance (Do not skip these questions)
Temporary Insurance Agreement (TIA) Health Questions
Have the persons listed as proposed insureds: YES NO
a. within the past 90 days, been admitted to a hospital or other
medical facility, been advised to be admitted, or had surgery
performed or recommended? ___ ___
b. within the past 90 days, been treated for heart trouble,
stroke, or cancer, or had such treatment recommended by a
physician or other medical practitioner? ___ ___
c. within the past 90 days, been advised to have a diagnostic
test which has not been performed? ___ ___
If any of the above questions is answered Yes, no agent of Allianz Life
Insurance Company of North America is authorized to accept money and no
insurance will take effect under the TIA.
Applicant and Agent have two options:
1. Continue to answer the following underwriting questions (beginning with
Section M);
OR
2. Have the Home Office continue with the underwriting questions
(go to Section R).
M. General Profile of Proposed Insured (required for all products)
Yes No
1. Are you a member or do you intend to become a member of the armed
forces, including reserves?.......................................
If YES, please give details
2. Within the last five years, have you been convicted of a felony or
are you currently on probation?....................................
If YES, in what county and state?
3. Do you intend to travel outside the U.S. or Canada within the next
two years?........................................................
If YES, where? Reason/anticipated date(s) for travel?
4. Have you engaged in, or do you intend to engage in, aviation
activities or sports such as powered racing or competitive vehicles
(including motorcycles, automobiles, motor boats, snowmobiles,
dirt bikes, and dune buggies), underwater diving, parachuting, hang
gliding, mountain climbing, rodeos, or bungee jumping?..............
If YES, what?
5. Have you had any moving violations or has your drivers license
been suspended or revoked in the last three years?...........
If YES, give drivers license number and type of violation(s)
6. Are you a US citizen or do you hold a permanent visa?.............
N. Proposed Insureds Medical History
Height ______________ Weight ______________________
Yes No
1. Have you used tobacco or nicotine in the last 12 months?..........
2. Within the past 10 years, have you used cocaine, marijuana, or any
other hallucinogenic or narcotic drug or controlled substance or
been advised to seek or had treatment for alcohol or drug dependency?
3. Are you presently taking medication including prescription, non-
prescription, or alternative remedies (i.e. holistic or herbal)?
4. Have you in the past five years, had any checkup, physical
consultation, surgery scheduled or completed, or had a diagnostic
test or treatment by a member of the medical profession or been
a patient in a hospital, clinic, or sanitarium?
5. Have you ever been medically diagnosed, received treatment for, or
had symptoms of high blood pressure, heart trouble, respiratory
problems, diabetes, kidney or liver disease, cancer or tumor,
paralysis, stroke, colon or back problems, dizziness, nervous or
mental disorders?................................................
DETAIL SECTION if yes answered to above questions
Quest# Illness, Injury or Examination Onset(Mo/Day/Yr) Recovery (Mo/Day/Yr)
Name & Address of Physician/Hospital
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Yes No
6. Has any family member been diagnosed with or treated for heart
disease, stroke, diabetes, cancer, kidney disease, or hyperlipidemia
(e.g. high cholesterol)?..............................................
Age at Death If Living, Current Age Condition Diagnosed
Parents
Grandparents
Brothers & Sisters
Age of Diagnosis If Deceased, Cause of Death
Parents
Grandparents
Brothers & Sisters
O. Variable LifeFund Questions(skip to Authorization Page if Variable LifeFund
is not chosen)
As the proposed Insured: YES NO
1. Do you require assistance or supervision, or are limited in any
way from performing any of the following daily activities:
bathing, dressing, toileting, managing money, using the telephone,
eating, mobility, or managing medications?.......................
2. Within the past five years, have you had symptoms of, been
diagnosed with, or treated by a member of the medical profession
for incontinence, imbalance, gait disturbance, or dizziness?......
3. Have you ever been diagnosed or treated by a member of the medical
profession for any type of sight impairment, or hearing loss,
confusion, dementia, Alzheimers disease, or memory?...............
4. Have you noted any lump in your breast, lymph nodes, or elsewhere
on your body?.....................................................
DETAIL SECTION if yes to any of above questions
Quest# Illness, Injury or Examination Onset(Mo/Day/Yr) Recovery (Mo/Day/Yr)
Name & Address of Physician/Hospital
P. Spouse Coverage
Yes No
1. Have you been diagnosed with a terminal illness (an illness or condition
which can be reasonably expected to result in death in 24 months or less), or
are you currently hospitalized, confined to a nursing home, hospice, bed,
wheelchair, or receiving home health
care?......................................................................
2. Do you use oxygen equipment, do you have any type of amputation due to
disease, or do you have an inability to control bowel or bladder functions,
other than stress incontinence?............................................
Q. Children Covered
Name of Child(ren):____________________ Date of Birth:____________________
____________________ ____________________
____________________ ____________________
Home Office Use Only (except PA and WV)
If Allianz Life Insurance Company of North America makes a change in this space
in order to correct any apparent errors or omissions, it will be approved by
acceptance of this Policy by the Owner(s); however, any material change must be
accepted in writing by the Owner(s).
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R. Authorization
To the best of my knowledge and belief, the statements and answers in this
application are complete, true and correctly recorded. Any required medical
examinations or additional questionnaires are part of this application.
By accepting the policy issued on this application, I agree to the terms of that
policy as written; and any corrections or changes made by Allianz Life Insurance
Company of North America (Allianz Life) and noted in the section FOR HOME
OFFICE USE ONLY. (Except, if the laws or regulations of the State where this
application is made require written agreement, no change in amount, class, plan
or benefits will be effective unless I agree in writing.)
Except for any coverage provided under a Temporary Insurance Agreement, I
understand that Allianz Life will not be responsible to provide insurance
applied for until a policy is issued and actually delivered to me; and at the
time of delivery, each persons health is as stated in this application; and the
first premium is actually paid.
If I selected the Allianz Variable LifeFund plan of insurance, I confirm that I
have received the Allianz LifeFund VUL Disclosure.
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION: I authorize Allianz Life to
obtain medical and other information on me or my minor children. This is true
for its reinsurers also. This includes information about drugs, alcohol and
mental illness. This information may be used to evaluate an application for life
insurance. It may also be used to evaluate a claim for benefits.
This information can be released by my (his/her) doctors. This includes medical
practitioners and pharmacists. It can also be released by medical and related
facilities. This includes hospitals, clinics, and facilities run by the
Veterans Administration. Information can also be released by the sources listed
below:
- - Insurers, - Reinsurers, - Medical Information Bureau, Inc. (MIB),
Employers, - Consumer Reporting Agencies (CRA)
All of the sources mentioned above, except for MIB,can give this information to
a CRA acting for Allianz Life.
Allianz Life can give this information to reinsurers, to the MIB and to
other insurers. This is true only if I have applied or apply to them for
insurance. Allianz Life can also give it to persons doing services for it, but
only if it is in connection with my (his/her) application or claim.
This authorization shall be valid for 26 months from the date shown below. I (or
my authorized representative) will be given a copy of this if I ask for it. A
copy of this shall be as valid as the original.
I have been given a copy of the NOTICE OF INSURANCE INFORMATION PRACTICES.
I would like to be interviewed if an investigative consumer report will be made.
__ Yes __No
Applicable for residents of the following states: AR, KY, LA, ME, NM, and OH.
Any person who knowingly, and with intent to defraud any insurance company,
submits an application or files a statement of claim containing any false,
incomplete, or misleading information, commits a fraudulent insurance act, which
is a crime, may be subject to criminal prosecution and civil penalties.
Applicable for residents of the state of CO: It is unlawful to knowingly provide
false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties
may include imprisonment, fines, denial of insurance, and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant for
the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado division of insurance within the department of
regulatory agencies.
Applicable for residents of DC: Any person who knowingly and with the intent to
defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act which is a crime.
____________________________________________________________________________
Date Signed City and State Signed In
____________________________________________________________________________
Signature of Proposed Insured (Parent or Legal Guardian Must Sign If Under
Age 18) Signature of Proposed Owner
____________________________________________________________________________
Registered Rep/Agents Printed Name
S. Tele-underwriting Signatures
Section required only if Home Office Tele-underwriting is chosen. This will be
signed upon delivery of Policy. (Please do not sign at time of application)
______________________________________________________________________________
Date Signed City and State Signed In
______________________________________________________________________________
Signature of Proposed Insured (Parent or Legal Guardian Must Sign If
Under Age 18) Signature of Proposed Insureds Spouse
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Agents Statement (required)
1. How long have you known any of the proposed insured(s)? _______________
2. Did you see the proposed insured(s) in person? __Yes __No. Are you
related to the proposed insured? __Yes __No If yes,state
relationship. ________________________________________________________
3. Is the insurance being applied for to replace or change any insurance
or annuities in force with this or any other comp-any __Yes __No.
If yes, give name of the company. If Yes, have the appropriate
state replacement forms been completed? ___Yes ___No
4. To your knowledge, has the proposed insured used tobacco within the
past 12 months? __Yes __No
5. Do you have any reason to believe the proposed insureds medical
history to be different than disclosed? __Yes __No
6. Have any underwriting requirements been ordered or will be completed?
If yes, please check those that apply below
___ Paramedical Exam ___ Home Office Urine Speciman (HOS) ___ EKG
___ Full Blood Profile (BLDPF)
Exams/labs are scheduled with __________________________________
Paramedical Company Name Phone Number
Date when scheduled exams are to take place
7. If premium payment was taken with the application, give amount. $______
I CERTIFY that I personally secured this application and recommend the proposed
insured(s) for insurance. Also, that I asked each question and recorded each
answer exactly as given.
For Registered Representative(s)
Agents to receive commissions must sign below:
_______________________________________________ ______________________________
Registered Representative Name(Please Print) Registered Representative Signature
_______________________________________________ ______________________________
Broker Dealer Name Authorized Signature of Broker Dealer if required
_______________________________________________ ______________________________
Branch Address (Street) Branch Telephone Number
_______________________________________________
_______________________________________________
(City, State, Zip Code)
_______________________________________________ _______________________________
Registered Representative Name(Please Print) Registered Representative Signature
_______________________________________________ ______________________________
Broker Dealer Name Authorized Signature of Broker Dealer if required
_______________________________________________ _______________________________
Branch Address (Street) Branch Telephone Number
_______________________________________________
_______________________________________________
Mail Applications To
For Regular Mail
Allianz Life-USAllianz Service Center
c/o PNC Bank
Box 824240
Philadelphia, PA 19182-4240
(800) 792-7198
For Overnight Delivery
Allianz Life-USAllianz Service Center
c/o PNC Bank
Attn: Box 4240
Route 38 and East Gate Drive
Moorestown, NJ 08057-4240
TEMPORARY INSURANCE AGREEMENT (TIA) Applicants Copy
Copy to applicant if premium payment collected. Otherwise do not detach.
Allianz Life Insurance Company of North America
USAllianz Service Center: 300 Berwyn Park, P.O. Box 3031, Berwyn, Pennsylvania
19312-0031
NOTICE TO APPLICANT PLEASE READ THIS AGREEMENT CAREFULLY. THE INFORMATION IT
CONTAINS IS IMPORTANT TO YOU. THE MAXIMUM AMOUNT OF COVERAGE UNDER THIS AND ALL
OTHER TEMPORARY INSURANCE AGREEMENTS WITH ALLIANZ LIFE WILL NOT BE MORE THAN
$250,000 FOR ANY PERSON TO BE INSURED. THE MAXIMUM PERIOD OF COVERAGE UNDER THIS
AGREEMENT IS 60 DAYS. MAKE ALL PREMIUM CHECKS PAYABLE TO ALLIANZ LIFE INSURANCE
COMPANY OF NORTH AMERICA. DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE PAYEE
BLANK.
CONDITIONS FOR TEMPORARY INSURANCE. Allianz Life Insurance Company of North
America, will provide limited temporary life insurance under the terms of this
agreement if advance payment of an amount equivalent to at least one months
premium has been paid to the agent in exchange for this agreement. Coverage will
begin on the date of this agreement on those individuals proposed for insurance
in the application, except for any person who answers YES to any of the TIA
Health Questions on page 3 of this application. TOTAL BENEFIT LIMITATION. If the
above conditions have been satisfied and any proposed insured dies while this
temporary insurance is in effect, Allianz Life will pay to the designated
beneficiary who would have received payment under the policy applied for, the
LESSER of: (1) the amount of death benefits applied for on that proposed insured
in the application INCLUDING any supplemental death benefit; LESS any existing
insurance with Allianz Life that is being reissued, exchanged or converted in
connection with the application; or (2) $250,000. This total benefit limit
applies to all insurance applied for under: (1) this and any other current
applications to Allianz Life and (2) any other Temporary Insurance Agreements
with Allianz Life.
DATE INSURANCE TERMINATES. Temporary life insurance
terminates automatically on the earliest of the following dates:
1. 60 days from the date of this agreement; or
2. the date coverage starts under the policy applied for; or
3. the date a policy, other than as applied for, is accepted or rejected by the
applicant; or
4. 10 days after the date of a counter-offer; or
5. the date Allianz Life declines the application, either by personal
notification or upon mailing of notice and refund of premium to the applicants
address as stated in the application.
SPECIAL LIMITATIONS. It is understood and agreed as follows:
1. No one is authorized to accept money and no insurance will take effect: (a)
on proposed insureds under 15 days of age or over age 70 (last birthday) on the
date of this agreement; or (b) when the amount applied for on any proposed
insured exceeds $250,000.
2. Fraud or material misrepresentations in the application invalidate this
agreement and Allianz Lifes only liability is for refund of any payment made.
3. If any proposed insured dies by suicide, Allianz Lifes liability under this
agreement is limited to a refund of any payment made.
4. No insurance will take effect under this agreement if the check or draft
submitted as payment is not honored by the bank.
5. No one but Allianz Lifes President or Secretary may change or waive the
terms of this agreement.
6. If the application is declined or withdrawn, Allianz Life will immediately
refund the advance payment shown above. In no event will insurance under this
agreement and under the policy issued on the application be effective at the
same time.
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NOTICE OF INSURANCE INFORMATION PRACTICES
To issue an insurance policy we need to obtain information about you and any
other persons proposed for insurance. Some of that information will come from
you and some will come from other sources. We may obtain information relating to
any proposed insureds mental and physical health, general character and
reputation, habits, finances, occupation, other insurance coverage, or
participation in hazardous activities.
This information may be obtained from physicians, medical professionals,
hospitals, clinics or other medical care institutions, or from the Medical
Information Bureau, public records, consumer reporting agencies, financial
sources, other insurance companies, agents, friends, neighbors and associates.
We may obtain information through exchanges of correspondence, by telephone or
by personal contact.
Information regarding your insurability will be treated as confidential. Allianz
Life Insurance Company of North America or its reinsurers may, however, make a
brief report thereon to the Medical Information Bureau, a nonprofit membership
of life insurance companies, which operates an information exchange on behalf of
its members. If you apply to another Bureau member company for life or health
insurance coverage, or a claim for benefits is submitted to such a company, the
Bureau, upon request, will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the Bureaus file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the Federal Fair
Credit Reporting act. The address of the Bureaus information office is Post
Office Box 105, Essex Station, Boston, Massachusetts 02112; telephone number
(617) 426-3660. Allianz Life Insurance Company of North America or its
reinsurers may also release information in its file to other life insurance
companies to whom you may apply for life or health insurance, or to whom a claim
for benefits may be submitted.
Furthermore, as part of our procedure for processing your insurance application,
an investigative consumer report may be prepared whereby information is obtained
through personal interviews with your neighbors, friends, associates and others
with whom you are acquainted. This inquiry and any subsequent investigative
consumer report update, which may also be requested, includes information as to
your character, general reputation, and personal characteristics. You have the
right to be personally interviewed if we order an investigative consumer report.
Please notify our agent if this is your wish. You are also entitled to receive a
copy of the investigative consumer report whether or not an interview is
conducted. You also have the right to make a written request within a reasonable
period of time to receive additional, detailed information about the nature and
scope of this investigation.
As a general practice, we will not disclose personal information about you to
anyone else without your consent, unless a legitimate business need exists or
disclosure is required or permitted by law. A description of the circumstances
under which information about you might be disclosed without your authorization
will be sent to you upon request.
You have a right of access to personal information we maintain in our files and
to request correction, amendment, or deletion of any information you believe to
be incorrect. You may request a description of established procedures which will
allow access to and correction of such personal information.
If you wish to have a more detailed explanation of our information practices,
including your rights of access to and correction of personal information,
please contact: Allianz Life - USAllianz Service Center, 300 Berwyn Park, P.O.
Box 3031, Berwyn, Pennsylvania 19312-0031, Telephone: 1-800-792-7198
DETACH AND DELIVER TO PROPOSED INSURED ON COMPLETION OF THIS APPLICATION.